Medicare - Prescription Drug Coverage (93.770)

Program

93.770 Medicare - Prescription Drug Coverage

Federal Agency

Agency: Department of Health and Human Services
Office: Centers For Medicare And Medicaid Services

Authorization

Authorized under the Medicare Prescription Drug, Improvement and Modernization Act of 2003, Public Law 108-173, as Section 1860D of the Social Security Act.

Program Number

93.770

Last Known Status

Active

Objectives

To provide prescription drugs to Medicare beneficiaries through their voluntary participation in prescription drug plans, with an additional subsidy provided to lower-income beneficiaries.

Types of Assistance

DIRECT PAYMENTS FOR A SPECIFIED USE

Uses and Use Restrictions

Payments will be made to participating prescription drug plans.

Eligibility Requirements

Applicant Eligibility

A non-governmental entity organized and licensed under State law as a risk-bearing entity eligible to offer health insurance in each State in which it is to offer a plan, meeting the requirements in 42 CFR 423.504 and 42 CFR 423.505.

Beneficiary Eligibility

Individuals who are entitled to Medicare benefits under Part A or enrolled in Part B, who reside in the plan's service area, and who are not enrolled in a Medicare Advantage plan, other than a Medicare savings account plan or private fee-for-service plan that does not provide qualified prescription drug coverage.

Credentials/Documentation

No Credentials or documentation are required. This program is excluded from coverage under OMB Circular No. A-87.

Application and Award Process

Preapplication Coordination

Preapplication coordination is not applicable. Environmental impact information is not required for this program. This program is excluded from coverage under E.O. 12372.

Application Procedure

This program is excluded from coverage under OMB Circular No. A-102. This program is excluded from coverage under OMB Circular No. A-110. Potential sponsors apply to CMS to become an approved prescription drug plan. Generally, individuals enroll directly with the prescription drug program sponsor. The sponsor forwards the enrollment and eligibility information to CMS, which verifies eligibility for the drug benefit. Some individuals who are entitled to both Medicare and Medicaid have been enrolled automatically. Low income beneficiaries may complete a subsidy application at any Social Security office or through their State Medicaid office.

Award Procedure

Payment will be made by CMS to the prescription drug plan sponsors.

Deadlines

Contact the headquarters or regional office, as appropriate, for application deadlines.

Range of Approval/Disapproval Time

Up to six months for plan sponsors.

Appeals

Sponsors whose applications to become a prescription drug plan sponsor are rejected have the right to a reconsideration and appeal process. Beneficiaries have the right to a reconsideration and appeal process for adverse coverage determinations.

Renewals

Contracts with sponsors may be renewed annually. Beneficiaries may enroll and disenroll from plans according to the timeframes established in 42 CFR 423.30-423.46.

Assistance Considerations

Formula and Matching Requirements

Statutory formulas are not applicable to this program.

Matching requirements are not applicable to this program.

MOE requirements are not applicable to this program.

Length and Time Phasing of Assistance

Indefinite. Method of awarding/releasing assistance: lump sum.

Post Assistance Requirements

Reports

Plans must provide periodic reports to CMS, enrollees and the general public on cost; utilization; availability, accessibility and acceptability of services; fiscal soundness and other information required by CMS. Plans must provide an annual report of business transactions and combined financial statements. Also, reports as required under the Employee Retirement Income Security Act of 1974. Plans must provide periodic reports to CMS, enrollees and the general public on cost; utilization; availability, accessibility and acceptability of services; fiscal soundness and other information required by CMS. Plans must provide an annual report of business transactions and combined financial statements. Also, reports as required under the Employee Retirement Income Security Act of 1974. Plans must provide periodic reports to CMS, enrollees and the general public on cost; utilization; availability, accessibility and acceptability of services; fiscal soundness and other information required by CMS. Plans must provide an annual report of business transactions and combined financial statements. Also, reports as required under the Employee Retirement Income Security Act of 1974. Plans must provide periodic reports to CMS, enrollees and the general public on cost; utilization; availability, accessibility and acceptability of services; fiscal soundness and other information required by CMS. Plans must provide an annual report of business transactions and combined financial statements. Also, reports as required under the Employee Retirement Income Security Act of 1974. Plans must provide periodic reports to CMS, enrollees and the general public on cost; utilization; availability, accessibility and acceptability of services; fiscal soundness and other information required by CMS. Plans must provide an annual report of business transactions and combined financial statements. Also, reports as required under the Employee Retirement Income Security Act of 1974.

Audits

This program is excluded from coverage under OMB Circular No. A-133. Periodic audits of plans by HHS, the Comptroller General or their designees. Periodic audits by CMS and the HHS Office of Inspector General (OIG) of plan cost reporting. Audit by CMS of financial records of at least one-third of participating plans every year.

Records

None.

Program Accomplishments

Fiscal Year 2008: As of January 30, 2007, approximately 39 million enrollees had comprehensive drug coverage through Part D or another credible source. Fiscal Year 2009: No Current Data Available Fiscal Year 2010: No Current Data Available

Financial Information

Account Identification

75-8308-0-7-571.

Obligations

(Insurance) FY 08 $43,740,793,000; FY 09 est $54,869,000,000; FY 10 est $64,131,000,000 - These funds represent benefit outlays.

Range and Average of Financial Assistance

Determined by plan offerings, number of enrollees, and utilization.

Regulations, Guidelines and Literature

Regulations governing this program were authorized under Section 1860D of the Social Security Act, as enacted under Public Law 108-173, and were published on January 21, 2005.

Related Programs

93.773 Medicare_Hospital Insurance; 93.774 Medicare_Supplementary Medical Insurance; 93.778 Medical Assistance Program

Information Contacts

Regional or Local Office

None.

Headquarters Office

Lynn Orlosky 7500 Security Boulevard, Baltimore, Maryland 21244 Email: lynn.orlosky@cms.hhs.gov Phone: 410-786-9064

Web Site Address

http://www.cms.hhs.gov.

Examples of Funded Projects

Not Applicable.

Criteria for Selecting Proposals

Not Applicable.